Congenital defects occur more commonly in preterm infants, so that surgery is frequently required. Organs and enzyme systems are very immature and meticulous attention to detail during anesthetic and surgical management is imperative if survival rates are to be high. The large body surface area and lack of subcutaneous fat make maintenance of body tem- perature even more difficult than in term infants, so that a high neutral thermal environment is essential. Respiratory fatigue occurs very easily and may be exacerbated by residual lung damage following mechanical ventilation, persistent fetal circulation and oxygen dependency. The response to exogenous vitamin K is less satisfactory than in term infants and there is an increased risk of bleeding. In addition, anemia is common because of reduced erythropoiesis, a short Special considerations for the premature infant 111
erythrocyte lifespan, and iatrogenic causes such as frequent blood sampling. Fluid and electrolyte management can be difficult insensitive losses are high and hypoglycemia and hypocalcemia occur easily, while renal function and the ability of the cardiovascular system to tolerate fluid loads are reduced.
Premature infants with a history of idopathic apneic episodes preoperatively are more prone than other infants to develop life-threatening apnea during recovery from anesthesia.81 It is recommended that infants born prema- turely who undergo anesthesia and surgery while less than 60 post-conceptual weeks of age should have respiratory monitoring for at least 12 hours postoperatively in order to prevent apnea-related complications.82 Intravenous caf- feine 5 mg/kg given intravenously at induction appears to reduce the risk of apneic episodes, but respiratory monitor- ing is still required.83
REFERENCES
1. Besag FMC, Singh MP, Whitelaw AGL. Surgery of the ill, extremely low birth weight infant: should transfer to the operating theatre be avoided?Acta Paediatr Scand1998;73:
5945.
2. Frawley G, Bayley G, Chondros P. Laparotomy for necrotizing enterocolitis: intensive care nursery compared with operating theatre.J Paediatr Child Health1999;35: 2915.
3. Ayre P. Endotracheal anaesthesia for babies with special reference to hare-lip and cleft palate operations. Anesth Analg1937;16: 3303.
4. Rees GJ. Neonatal anaesthesia.Br Med Bull1958;14: 3841.
5. Tochen ML. Orotracheal intubation in the newborn infant: a method for determining depth of tube insertion.J Pediatr1979;
95: 10501.
6. Harnett M, Kinirons B, Heffernan Aet al.Airway complications in infants: comparison of laryngeal mask airway and the facemask-oral airway.Can J Anaesth2000;47: 31518.
7. Bahk J-H, Choi I-H. Tracheal tube insertion through laryngeal mask airway in paediatric patients. Paediatr Anaesth 1999;
9: 956.
8. Ellis DS, Potluri PK, O’Flaherty JE, Baum VC. Difficult airway management in the neonate: a simple method of intubating through a laryngeal mask airway. Paediatr Anaesth 1999;
9: 4602.
9. Delrue V, Veyckemans F, De Potter P. Modification of the LMA no. 1 for diode laser photocoagulation in ex-premature infants.
Paediatr Anaesth2000;10: 3456.
10. Walker I, Lockie J. In: Sumner E, Hatch DJ (eds). Paediatric anaesthesia. London: Arnold, 2000: 174.
11. Anand KJS, Hickey PR. Pain and its effects in the human neonate and fetus.N Engl J Med1987;317: 13219.
12. Anand KJS, Sippell WG, Aynsley-Green A. Randomised trial of fentanyl anaesthesia in preterm babies undergoing surgery.
Lancet1987;1: 243247.
13. McGowan FX Jr., Davis PJ. Anesthetic-related neurotoxicity in the developing infant: of mice, rats, monkeys and, possibly, humans.Anesth Analg2008;106: 1599602.
14. Sanders RD, Davidson A. Anesthetic-induced neurotoxicity of the neonate: time for clinical guidelines?Pediatr Anesth2009;
19: 11416.
15. Salanitre E, Rackow H. The pulmonary exchange of nitrous oxide and halothane in infants. Anesthesiology 1969; 30:
38894.
16. Cook DR. Neonatal anesthetic pharmacology: a review.Anesth Analg1974;53: 5448.
17. Steward DJ, Creighton RE. The uptake and excretion of nitrous oxide in the newborn.Can Anaesth Soc J1978;25: 21517.
18. Hatch D, Fletcher M. Anaesthesia and the ventilatory system in infants and young children.Br J Anaesth1992;68: 398410.
19. Sampaio MM, Crean PM, Keilty SR, Black GW. Changes in oxygen saturation during inhalation anaesthesia in children.Br J Anaesth1989;62: 199201.
20. Raftery S, Warde D. Oxygen saturation during inhalation induction with halothane and isoflurane in children: effect of premedication with rectal thiopentone.Br J Anaesth1990;64:
1679.
21. Warde D, Nagi H, Raftery S. Respiratory complications and hypoxic episodes during inhalation induction with isoflurance in children.Br J Anaesth1991;66: 32730.
22. Wolf AR, Lawson RA, Dryden CM, Davies FW. Recovery after desflurane anaesthesia in the infant: comparison with isoflur- ane.Br J Anaesth1996;76: 3624.
23. Kataria B, Epstein R, Bailey Aet al.A comparison of sevoflurane to halothane in paediatric surgical patients: results of a multicentre international study. Paediatr Anaesth 1996; 6:
28392.
24. O’Brien K, Robinson DN, Morton NS. Induction and emergence in infants less than 60 weeks post-conceptual age: comparison of thiopental, halothane, sevoflurane and desflurane. Br J Anaesth1998;80: 4569.
25. Sale SM, Read JA, Stoddart PA, Wolf AR. Prospective compar- ison of sevoflurane and desflurane in formerly premature infants undergoing inguinal herniotomy. Br J Anaesth 2006;
96: 7748.
26. Constant I, Seeman R, Murat I. Sevoflurane and epileptiform EEG changes.Pediatr Anesth2005;15: 26674.
27. Gordana P, Vlajkovic MD, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg 2007;
104: 8491.
28. Eisele JH, Milstein JM, Goetzman BW. Pulmonary vascular responses to nitrous oxide in newborn limbs. Anesth Analg 1986;65: 624.
29. Hickey PR, Hansen DD, Stafford Met al.Pulmonary and systemic haemodynamic effects of nitrous oxide in infants with normal and raised pulmonary vascular resistance.Anesthesiology1986;
65: 3748.
30. Allegaert K. Is Propofol the perfect hypnotic agent for procedural sedation in neonates?Curr Clin Pharmacol 2009;
4: 846.
31. Ghanta S, Abdel-Latif ME, Lui Ket al.Propofol compared with morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized trial.Pediatrics2007;119: 124855.
32. Dubois MC, Troje C, Martin C et al. Anesthesia in the management of pyloric stenosis. Evaluation of the combination of propofol-halogenated anesthetics. Ann Fr Anesth Reanim 1993;12: 56670.
33. Friesen RH, Henry DB. Cardiovascular changes in preterm neonates receiving isoflurane, halothane, fentanyl and keta- mine.Anesthesiology1986;64: 23842.
34. Meakin GH. Neuromuscular blocking drugs in infants and children.Contin Educ Anaesth Crit Care Pain2007;7: 1437.
112 Anesthesia
35. Rawicz M, Brandom BW, Wolf A. The place of suxametho- nium in pediatric anesthesia. Pediatr Anesth 2009; 19:
56170.
36. Goudsouzian NG, Donlon JV, Savarese JJ, Ryan JF. Re-evaluation of dosage and duration of action of d-tubocuraine in the pediatric age group.Anesthesiology1975;43: 41625.
37. Driessen JJ, Robertson EN, Booij LH. Acceleromyography in neonates and small infants: baseline calibration and recovery of the responses after neuromuscular blockade with rocuronium.
Eur J Anaesth.2005;22: 1115.
38. Goudsouzian NG. Atracurium infusion in infants.Anesthesiology 1988;68: 2679.
39. Nightingale DA. Use of atracurium in neonatal anaesthesia.Br J Anaesth1986;58(Suppl. 1): 326.
40. Brandom BW, Rudd GD, Cook DR. Clinical pharmacology of atracurium in paediatric patients.Br J Anaesth 1986;55:
11721S.
41. Brandom BW, Woelfel SK, Cook DRet al.Clinical pharmacology atracurium in infants.Anesth Analg1984;63: 30912.
42. Fisher DM, Miller RD. Neuromuscular effects of vecuronium (ORG NC45) in infants and children during N2O, halothane anesthesia.Anesthesiology1983;58: 51925.
43. Brandom BW, Meretoja OA, Simhi Eet al.Age related variability in the effects of mivacurium in paediatric surgical patients.Can J Anaesth1998;45: 41016.
44. Cheng CA, Aun CS, Gin T. Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children.
Paediatr Anaesth2002;12: 1405.
45. Driessen JJ, Robertson EN, Van Egmond J, Booij LH. The time-course of action and recovery of rocuronium 0.3 mg x kg(-1) in infants and children during halothane anaesthesia measured with acceleromyography.Paediat Anaesth2000;10:
4937.
46. Groudine SB, Soto R, Lien Cet al.A randomized, dose-finding, Phase II study of the selective relaxant binding drug, Sugammadex, capable of safely reversing profound rocuronium- induced neuromuscular block. Anesth Analg 2007; 104:
55562.
47. Hain WR, Mason JA. Analgesia for children.Br J Hosp Med 1986;36: 3758.
48. Cook DR. Pediatric anesthesia: pharmacological considerations.
Drugs1976;12: 21221.
49. Way WL, Costley EC, Way EL. Respiratory sensitivity of the newborn infant to meperidine and morphine. Clin Pharmacol Ther1965;6: 45461.
50. Lynn AM, Slattery JT. Morphine pharmacokinetics in early infancy.Anesthesiology1987;66: 1369.
51. Berde CB, Sethna NF. Analgesics for the treatment of pain in children.N Engl J Med2002;347: 1094103.
52. Lynn A, Nespeca MK, Bratton SLet al.Clearance of morphine in postoperative infants during intravenous infusion: the influence of age and surgery.Anesth Analg1998;86: 95863.
53. Yaster M. The dose response of fentanyl in pediatric anesthesia.
Anesthesiology1987;66: 4335.
54. Eck JB, Lynn AM. Use of remifentanil in infants. Paediatr Anaesth1998;8: 4379.
55. Wee LH, Moriarty A, Cranston A, Bagshaw O. Remifentanil infusion for major abdominal surgery in small infants.Paediatr Anaesth1999;9: 41518.
56. Kehlet H. Surgical stress: the role of pain and analgesia.Br J Anaesth1989;63: 18995.
57. Kehlet H, Dahl JB. The value of ‘multimodal’ or ‘balanced analgesia’ in postoperative pain management. Anesth Analg 1993;77: 104856.
58. van der Marel CD, Peters JW, Bouwmeester NJet al.Rectal acetaminophen does not reduce morphine consumption after major surgery in young infants.Br J Anaesth2007;98: 3729.
59. Tremlett M, Anderson BJ, Wolf A. Pro-con debate: is codeine a drug that still has a useful role in pediatric practice?Pediatr Anesth2010;20: 18394.
60. Eustace N, O’Hare B. Use of nonsteroidal anti-inflammatory drugs in infants. A survey of members of the Association of Paediatric Anaesthetists of Great Britain and Ireland.Pediatr Anesth2007;17: 4649.
61. Mahe V, Ecoffey C. Spinal anesthesia with isobaric bupivicaine in infants.Anesthesiology1988;68: 6013.
62. Shenkman Z, Hoppenstein D, Litmarrowitz I. Spinal anaesthesia in 62 premature, former-premature or young infants technical aspects and pitfalls.Can J Anaesth2002;49: 2629.
63. Krane EJ, Haberkern CM, Jacobson LE. Postoperative apnea bradycardia and oxygen desaturation in formerly premature infants: prospective comparison of spinal and general anesthe- sia.Anesth Analg1995;80: 713.
64. Williams RK, McBride WJ, Abajian JC. Combined spinal and epidural anaesthesia for major abdominal surgery in infants.
Can J Anaesth1997;44: 51114.
65. Somri M, Gaitini L, Vaida S et al. Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison be- tween spinal and general anaesthesia.Anaesthesia1998;53:
7626.
66. Willschke H, Marhofer P, Machata A-M, Lo¨nnqvist PA. Current trends in paediatric regional anaesthesia. Anaesthesia 2010;
65(Suppl. 1): 97104.
67. Stephen CR, Ahlgren EW, Bennett EJ. Elements of pediatric anesthesia. Springfield, IL: Charles C Thomas, 1970: 42.
68. Meakin G, Sweet PT, Bevan JC, Bevan DR. Neostigmine and edrophonium as antagonists of pancuronium in infants and children.Anesthesiology1983;59: 31621.
69. Leelanukrom R, Cunliffe M. Intraoperative fluid and glucose management in children.Paediatr Anaesth2000;10: 3539.
70. Louik C, Mitchell AA, Epstein MF, Shapiro S. Risk factors for neonatal hyperglycemia associated with 10% dextrose infusion.
Am J Dis Child1985;139: 7836.
71. Bush GH, Steward DJ. Can persistent cerebral damage be caused by hyperglycaemia?Paediatr Anaesth1995;5: 3857.
72. Anon. Human albumin administration in critically ill patients:
systematic review of randomised controlled trials. Cochrane Injuries Group Albumin Reviewers.BMJ1998;317: 23540.
73. Spitz L, Kiely E, Brereton RJ. Esophageal atresia: five year experience with 148 cases.J Pediatr Surg1987;22: 1038.
74. Kosloske AN, Jewell PF, Cartwright KC. Crucial bronchoscopic findings in esophageal atresia and tracheoesophageal fistula.
J Pediatr Surg1988;23: 46670.
75. Cartlidge PHT, Mann NP, Kapila L. Preoperative stabilisation in congenital diaphragmatic hernia. Arch Dis Child 1986; 61:
12268.
76. Langer JC, Filler RM, Bohn DJ et al. Timing of surgery for congenital diaphragmatic hernia: is emergency operation necessary?J Pediatr Surg1988;23: 7314.
77. Bouchut J-C, Dubois R, Moussa M et al. High frequency oscillatory ventilation during repair of neonatal congenital diaphragmatic hernia.Paediatr Anaesth2000;10: 3779.
References 113
78. Tobias JD, Burd RS. Anaesthetic management and high frequency oscillatory ventilation. Paediatr Anaesth2001;11:
4837.
79. Cote CJ. The anesthetic management of congenital lobar emphysema.Anesthesiology1978;49: 2968.
80. Eger EI, Saidman LJ. Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology 1965;
26: 616.
81. Liu LMP, Cote CJ, Goudsouzian NGet al.Life threatening apnea in infants recovering from anesthesia. Anesthesiology 1983;
59: 50610.
82. Kurth CD, Spritzer AR, Broennle AM, Downes JJ. Postoperative apnea in preterm infants.Anesthesiology.1987;66: 4868.
83. Welborn LG, de Soto H, Hannallah RSet al.The use of caffeine in the control of post-anesthetic apnoea in former premature infants.Anesthesiology1988;68: 76998.
114 Anesthesia